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Home My Public Portal About6026 CAMELLIA AVE_Plumbing__ .WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT �I•�iereliy affli�rr�that I have a certlflcgte of consent to self 204=e DPW 6/87 Insure, or a certificate of Workers' Compensatlon Irsurance, 76A867A or a certified copy thereof (Sec. 3860, Lob. -) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Porky No._//Company.—F7� ❑ ified copy It hereby furnished. ;T—1—9a FOR APPLJCANT TO FILL IN(PRINT OR TYPE) BUILDING e01-- Certified copy Is filed with the county building Inspec- tion departme.,nt./ApNUMBER �TURE OR ITEM O FEE LOCALITY / Date v pl IWnt WATER QQSET CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TU8 D Cis ST. COMPUNSATIO 11 NS U RANCE SHOWER OWN6R (This wflan rseed not be completed If the work Imro1v by MAR the pwmItt Is fpr one hpndred do1{ars ($100)or loss.) LAVATORY ADDRESS 1 certify that In the performance of the work for which this / permit Is lwubd, I shall not employ any persOA In any manner SINK Crry 711 NO. po so as to become subject to the Worker'Compertsatlon Laws. DISHWASHER CONTRACTOR Data AIlcant CLOTHES WASHER ADD NOTICE TCS APPLICANT: if, after making this Certificate of SWIMMING POOL Exemption, you should become subject to the Workers' C TEL. NO Compensation provisions of the Labor Code, you must forth- LAWN SPRINnER SYSTEM U with comply with such provisions or thls permit shall be STATEUC deemed revoked. WATER BEATER LIM111E NO. CLASS G LICENSED CONTRACTORS DECLARATION DiSTR1CT NO. BY I hereby afprm-that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS 01 (commencing with Settlors 7000) of Division 3 of the Business OUTLETS OVER and Profealorq Code,and my license is In full force and effect. S PER SYSTEM FINAL VALIQATION rY1 llcerue Number �a`fi �ic. C{ws� DATE ` , FINAL Contrattgr AAa U2LO' Date — BY ❑ I am exempt under Sec. B.BP.C. for this reason 12 Pfan Chock fee / Dais: PLUMBING PERMIT I$SIJING 1,a SignatureZ, TOTAL 1$ 00 Plan check applicant SINGLE FAMILY FIOIME OWNER-BUILDER DECLARATION Namo A{:(.r 1 1 tier*by affIrm that I am ipxempt from the Contractors License L,aw for the following reason (Sectlon 7031.5, Business and Address 3307 i4Z.Clr-1 Professions Code): City Tql. No. 1 I� ❑ I, as owner of the property, will do the work and the structure Is not intended w offered for sale (Sectionoil. Ti IT L 243- 00 }ss 7044, BVslnand professlons Code). 6-ECK 2431.W 4 .W CONSTRUCTION LENDING AGENCY �y.��t�-� I hereby affirm that there Is construction lending agency far tr�Y4f� .M the performance of the work for which this permit Is Issued (Sec. W, Civ. C.). Lenders Name- }� 2/24/r- 18711G:1IL Lenders Address I certify that 1 have read this application and state that the , above Informotlon Is correct. I agree to comply wlth all County ordinances and State lawsu.lating Plumbing, and hereby authorize,reprelentatives of this County to enter upon the above-m ntloned pr6perty for Inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature er ture of Pm ee ��ebz WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I,hereby affirm that I have a certificate of consent to self 20-W28 DPW 8/87 C I Insure, or a terttficate of Workws Compensation Insurance, 76ABWA lul or a cwllfied copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No.,///— =Company , Ified copy Is hereby furnished. % BUILDING FOR APPi1GM(T TO RLL RJ(PRINT OR TYPE) ADDRESS D 4Certtfied copy Is filed with the county building Inspec NUMBER FIXTURE OR ITEM O FEE tion department. LOC11rfY Date Appll4ant WATER CLOSETNEARSi CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TDB O MM ST COMPENSATION INSURANCE SHOWER 01NtS2 (This section need not be mnpWfed If Ila work Invahed by MAIL the permft Is for am hundred dollar($100)or 1ess.) LAVATORY ADDRESS I certify that In the performance of the work for which this ?topermit Is Issued, I shall not employ anso y Person In any manner SiNX Cry Te- �' ! so as to become sublect to the Workers Compensation Laws. D1.54-1WASHER CO,NTRA4TOR Date ATllcont CLOTHES WASHER ADDRlss NOTICE TO APPLICANT: If, after making this Certificate of �7 Exemption, you should become subject to the Worker' SWVAAAJNO POOL RECEPTOR Compensation provisions of the Labor Cade, you must forth- LAWN SPRINKLER SYSTEM CITY TEL Na with comply with such provisions or this permit shall be STATE LIG deemed revoked. WATER HEATER LICFTRSE NO. LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCEM BY I hereby affirm that I am Itce Aed under provIslorts of Chapter 9 GAS STEM ODTLM �� (commencing with Section 7000) of DhiWon 3 of the Business OUTLETS OVER and Professions Co*and my license Is In full force and e#Oct. 5 PER SYSTEMFINAL VALIDATIpN �r�/� DATE —7, Llcense Numb¢r Ic Class /� 'U,'.,�/7+ Q FINAL ContractorX12 2✓f Date �, BY ❑ I am Exempt under Sec. B.BP.t for thlt reason Plan check fee en Z Date. PLUMBING PERMrf ISSUING FEE$ Signature TOTAL FEi � SINGLE FAMILY Plan check applicant r - HOME OWNER-BUILDER DECLARATION Name 'ICT i I hereby affirm that I am exempt from the Contractor's Llcense �y�' T Law for the following reason (Section 7031.5, Busmen and 'gess ,31 r ::43.1X: Profealons Cods): city Tel. No. ❑ 1 I3 1,'as owner of the property, will do the work and the structure Is not Intended or offered for sale (Section , TOTAL 2-43 - 00 7041, Buslness and Professions Code}. CONSTRUCTION LENDING AGENCY � � i �'•�I I hereby affirm that there Is a construction lending agency for DWI .00 I the performance of the work for which this permlt Is Issued (Sec. 3097, Civ. C.). Lenders Name � 1 Lenders Address 1370 1 AM In,:11 I certtfy that I have read this application and stats that the ► above Information Is correct. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby authorize ropratentatives of this County to enter upon the above-me lonsd'properfy for Inspection purposes. SEE REVERSE FOR EXPLANATORY LAN"A(i! . Slgrwture of Perml se Dat